Name (Print Last, First, Middle Initial):

Date of Birth:

Address:


Telephone Number:

IF YOU ARE UNDER 18 YEARS OF AGE, GIVE NAME OF PARENT OR GUARDIAN, ADDRESS, AND TELEPHONE NUMBER:


CHECK HIGHEST LEVEL OF EDUCATION:

Elementary School: 1___ 2___ 3___ 4___ 5___ 6___ 7___ 8___

High School: 9___ 10___ 11___ 12___

College: 1___ 2___ 3___ 4___ 5___ 6___

Other:

What volunteer work would you like to do?


What days and times would you be able to volunteer?


What qualifications, skills, hobbies, interests, training, or education do you have that would relate to the volunteer job you are applying for?


Briefly describe any past volunteer experience:


Briefly describe past and present employment:


Please list two references (one work and one personal) with telephone numbers:


Please specify any physical limitations that may influence your volunteer activities:

The following information is provided to comply with the Privacy Act (PL 93-579), U.S.C. 301 and 7 CFR 260 authorizing acceptance of the information requested on this form. The data will be used to contact applicants and to interview, screen, and select them for volunteer assignments. Furnishing this data is voluntary.

Signature (Sign in ink):


Date: